Text-based therapy might be as effective as video for depression

A new study suggests that psychotherapy delivered through text-based messaging can be as effective as live video sessions for treating depression. The research, which compared outcomes for hundreds of adults using a commercial mental health platform, also found that patients were less likely to drop out of message-based therapy. These findings were published in JAMA Network Open.

Depression is a leading cause of disability worldwide, and while effective psychotherapies exist, many people face barriers to accessing care. Video-based therapy has expanded access by removing geographic constraints, but it still requires patients and therapists to coordinate schedules for live appointments.

Researchers wanted to investigate a more flexible alternative: message-based psychotherapy, which allows patients and therapists to communicate asynchronously through text, audio, or video messages. This method allows for more frequent contact and creates a written record of sessions that patients can review.

A team of researchers from the University of Washington partnered with the commercial digital mental health company Talkspace to conduct a large-scale clinical trial. They aimed to directly compare the effectiveness of message-based therapy with video-based therapy and to see if combining the two approaches could help patients who did not initially respond to treatment.

To conduct the study, the research team recruited 850 adults from across the United States who were diagnosed with depression. These participants were randomly assigned to one of two treatment groups for 12 weeks. One group received message-based psychotherapy, where they could exchange messages with their therapist at any time. The other group received weekly video-based psychotherapy, which consisted of scheduled 30- to 45-minute live video sessions. The study was designed in two phases.

After the first six weeks, the researchers assessed which participants were showing improvement. Those who were not responding to their assigned treatment were then randomly assigned again to a combination of therapies. For instance, non-responders in the messaging group had either weekly or monthly video sessions added to their treatment. Similarly, non-responders in the video group had messaging added to their existing sessions.

Throughout the study, participants regularly completed questionnaires to measure the severity of their depression symptoms and their ability to participate in social roles and activities. The researchers also collected data on treatment engagement, the quality of the patient-therapist relationship, and overall satisfaction with the care they received.

The results showed no significant difference in clinical outcomes between the two methods. Both groups experienced similar reductions in depression symptoms and similar improvements in social functioning over the 12-week period. The proportion of patients who responded to treatment or achieved remission from depression was nearly identical for both message-based and video-based therapy.

A notable difference appeared in patient engagement. The study found that participants assigned to weekly video sessions were significantly more likely to disengage from treatment within the first five weeks compared to those in the messaging group.

When examining the patient-therapist relationship, known as the therapeutic alliance, the researchers observed a nuanced pattern. Among patients who were not responding well to treatment early on, those in the video therapy group tended to report a stronger bond with their therapist compared to non-responders in the messaging group. This finding suggests that live video interaction may help in building initial rapport.

However, for patients who did not improve after six weeks, adding the alternative therapy method did not lead to better outcomes. Combining messaging with video for non-responders was not more effective than continuing with a single modality. The frequency of the added video sessions, whether weekly or monthly, also did not make a difference in patient improvement. Both groups reported high levels of satisfaction, though participants who received video therapy were slightly more likely to recommend the treatment to others.

The study has several limitations. It did not include a no-treatment control group, which means the researchers cannot completely rule out the possibility that some improvement occurred naturally over time. They note, however, that the remission rates in the study were higher than the typical rates of spontaneous recovery from depression.

The research team also disclosed potential conflicts of interest, as several of the study’s authors were employees of Talkspace, the platform on which the therapy was delivered. The study was funded by the National Institute of Mental Health, which had no role in the study’s design, data analysis, or the decision to publish the results.

For future research, the authors suggest exploring ways to enhance the therapeutic alliance in message-based therapy from the outset. One possibility could be incorporating an initial video session to help establish a stronger connection between the patient and therapist. The findings support the expansion of insurance coverage for message-based psychotherapy, which would make this flexible and effective form of treatment more widely accessible.

The study, “Message-Based vs Video-Based Psychotherapy for Depression: A Randomized Clinical Trial,” was authored by Michael D. Pullmann, Julien Rouvere, Patrick J. Raue, Isabell R. Griffith Fillipo, Brittany A. Mosser, Patrick J. Heagerty, Nicole Fridling-Cook, Aarthi Padmanabhan, Thomas D. Hull, and Patricia A. Areán.